Client Services
Adoption Assistance Reimbursement Claim Form
Instructions
Please provide all of the following information and sign this form. Provide copies of bills or records that are sufficient to substantiate who (name and address) provided the services or goods, reason for the charges and the dates and amounts of the charges. Submit this form and substantiation to ____________________________. Retain copies of all documents for your records.
Child's Name: _______________________________________
SSN, TIN, ATIN (if available): ____-___-____
Child's DOB: ____/___/____
Child's Country of Birth: ____________________________________
When will the adoption be finalized? ______________________________________________
If the child is a U.S. citizen or resident, is this an adoption involving a child with special needs, (i.e., the state has determined that the child cannot or should not be returned to the birth partners' home and probably will not be adopted unless adoption assistance is provided)?
____ Yes ____ No.
If yes, please explain the special needs and provide specific documentation of the state determination:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
| Type of Expense | Date Expense Incurred | Amount | ||
Qualifying Adoption Expenses: Qualified adoption expenses include, but are not limited to, reasonable and necessary adoption fees, court costs, attorney fees, traveling expenses (including amounts spent for meals and lodging) while away from home, and other expenses directly related to, and whose principal purpose is for, the legal adoption of an eligible child.
Non-Qualifying Adoption Expenses: Non-qualifying expenses are those that violate state or federal law; expenses for carrying out any surrogate parenting arrangement; expenses for the adoption of a spouse's child; expenses paid using funds received from any other source (such as another employer or from a federal, state, or local program); or expenses taken as a credit or deduction under any other federal income tax rule.
I hereby certify that all items requested to be reimbursed comply with the [ Name of Company ] Adoption Assistance Plan and such items have not and will not be covered or reimbursed by any employer, governmental program, or any other person or entity. I further certify that such items will not be deducted or taken as tax credits on my personal federal income tax returns for any year.
Employee Signature: _______________________________________
Date:______________________________
Print Name: _______________________________________
SSN: _____-___-_____
Street Address: ______________________________________________
City/State/Zip: _________________________________________
